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Written on 19th November 2021 by

Healthcare safety watchdog, HSIB, has published its latest report into the care received by COVID patients who need help with their breathing. Their investigation followed the death of a man who had pressed the call bell for help whilst left on respiratory (breathing) support in the side room of a hospital ward. Recognising the additional pressures faced by hospitals during the first and second COVID wave, HSIB sets out the dangers of nursing acutely unwell COVID patients who cannot breathe without support outside of a critical care setting and urges healthcare organisations to check their compliance with published national guidance.

Helping patients to breathe - What is CPAP?

HSIB’s investigation looked into what happened when patients were admitted to hospital with COVID because they needed help with their breathing.  Some patients could be treated with oxygen therapy, in which they breathed in oxygen through a face mask or through small tubes placed inside their nose.

Patients with more severe breathing difficulties, known as respiratory failure, were given oxygen-enriched air at constant pressure through tubes and a mask or a hood. This treatment is called continuous positive airway pressure or CPAP. CPAP is less invasive than ventilation (which uses a machine to breathe for the patient) and is given when the patient is awake and can breathe on their own. CPAP is usually given to patients in high dependency or critical care units, which have a high staff-to-patient ratio, and whose  staff are trained and experienced in giving CPAP. 

When a patient receives CPAP, small particles are released from the patient’s respiratory tract ( nose, throat, airway and lungs) into the air. During COVID this presented an infection risk to those around them. Suspected COVID patients were, therefore, nursed away from other patients. The numbers of people admitted to hospital with respiratory failure during the first and second waves of the pandemic meant that there were not enough beds in critical care and high-dependency units, and hospitals had to find other places, away from other patients, to nurse them.

The reference event – the patient’s experience

Like many HSIB investigations, this one was triggered by the experience of one patient. The man was admitted to hospital with COVID-19 symptoms. He was given oxygen therapy to help him breathe, but when his oxygen levels repeatedly dropped below safe levels, his treatment was changed to CPAP. To reduce the infection-risk to other patients and staff from his CPAP treatment, he was moved to the side room of a medical ward. His condition was monitored and he received care from the doctors and nurses on the ward, with visits from the critical care team. On the second evening of his stay in hospital he called for help using his call bell. The ward was short staffed and extremely busy with overlapping priorities and new patients being admitted. Whilst a nurse was preparing to enter the patient’s side room, whilst putting on her PPE she noticed through the window that he was lying, not moving, on the floor. His CPAP tube had become disconnected from his mask, leaving him without breathing support. The nurse entered the room and called the resuscitation team via the emergency buzzer, but attempts to resuscitate him failed and he died.

What did HSIB’s national investigation into use of CPAP in hospital side rooms find?

After working with the hospital where the patient in the example died, HSIB launched a national investigation. Their report, Treating COVID-19 patients using continuous positive airway pressure (CPAP) outside of a critical care unit, highlighted many general issues that were already known to affect the NHS’s response to the COVID-19 pandemic. These include:

  • gaps in staffing and skills needed to meet the demand for patient care, on wards and in critical care environments;
  • challenges with giving treatment outside normal clinical areas;
  • challenges for staff who are working outside their normal clinical areas;
  • limitations involved in using equipment, particularly if used in a different environment than originally intended.

In relation to the specific investigation into using CPAP in a hospital ward side room, HSIB found:

• COVID patients who are treated with CPAP need close monitoring and observation. There are safety risks to the patient in being nursed on CPAP in a side room unless the nurses can monitor them (remotely) from the nurses’ station via a central monitoring system which shows their monitors, screens and alarms. Patients cannot be seen by staff and their equipment alarms (designed to alert staff to a problem) often can’t be heard outside the room.

• Caring for acutely unwell patients on CPAP outside of critical care/high-dependency units leads to additional staffing problems.

 • During the first and second waves of the pandemic, staffing levels were affected by staff having to self-isolate.

• Staff who are caring for COVID patients on CPAP on general wards need to be trained and competent so that they can confidently deliver appropriate care.

• National guidelines set a mandatory staffing ratio of 1:2, ensuring that there is at least one nurse responsible for every two patients on CPAP and other non-invasive forms of breathing support. This is because these patients are at high risk of deterioration, unplanned admission to a critical care unit and death. The higher the level of acute illness on a ward or unit, the more staff are needed. In the case of the man who died in the example reference event, the hospital could not meet the required nurse-to-patient ratio on the medical ward.

• HSIB referred to guidance published by the Intensive Care Society, the British Thoracic Society, Getting It Right First Time and other organisations. Their recommendations include:

  • Hospitals should set up respiratory support units that are staffed in line with national recommendations, including a minimum nurse to patient ratio of 1:4, with nurses trained in giving CPAP and high-flow nasal oxygen.
  • Patients who need non-invasive respiratory support, such as CPAP, should be centrally monitored.
  • Hospitals should have protocols setting out how often nurses should check on patients, especially for acutely unwell patients in side rooms.
  • Hospitals should have checklists, such as those drawn up by the  British Thoracic Society and Intensive Care Society, for the safe use of CPAP or other non-invasive ventilation outside of critical care and high-dependency units.
  • Minimum safe staffing levels should be followed when caring for patients who need non-invasive respiratory support.
  • Where possible, organisations should buy CPAP devices that allow remote monitoring.
  • Staff who care for patients needing non-invasive respiratory support outside of critical care settings should meet training and competency requirements.

HSIB made no new safety recommendations but encouraged hospitals to comply with the existing guidance when caring for COVID-19 patients needing CPAP and other breathing support, outside of a critical care setting.

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